The Health IT Standards Committee has begun exploring some of the functions that electronic health records (EHRs) should be capable of performing in stage 2 of meaningful use, with the use of health information exchange by providers to send patients their information to a personal health record (PHR) a prominent example.

Healthcare providers will have a choice in health information exchange in later stages of meaningful use now that different methods are taking shape. Certification and standards criteria in meaningful use stages 2 and 3 should support various methods of exchange when they are coupled with standards and robust testing, according to committee members at their meeting March 29.

Dr. John Halamka, committee co-chair, posed the question about whether the committee should consider recommending as a stage 2 objective that a provider be able to perform certain kinds of transaction using one of the methods of exchange.

The method of exchange would be up to the provider, whether it is the nationwide health information network (NHIN) Exchange currently used for large organizations; the Direct Project, which is a secure email based on streamlined NHIN standards and services; or Connect, an open source representation of NHIN.

For example, a provider could send information from an EHR system to a patient's personal health record (PHR).

"Imagine how the ecosystem could suddenly explode to become more patient centric if every EHR were capable of sending at least one transaction to a PHR using Direct?"  Halamka said. Halamka is also chief information officer of Harvard Medical School and Beth Israel Deaconess Medical Center.

Under stage 1 of meaningful use, providers are supposed to be able to give patients a copy of their record within three business days. If PHR vendors supplied patient customers with a secure Direct email address, then a provider's EHR system could send the clinical information directly to the PHR. Halamka cited Microsoft's HealthVault, which has incorporated Direct in its product.

"It makes my life easier and [makes] more patient engagement in stage 2 and 3 a lot easier," he said.

To make health information exchange generally more useful and successful in stage 2, the Office of the National Coordinator for Health IT continues to work at making the technical descriptions for deploying the standards more specific and to develop a set of standard vocabulary that most providers use, said Dr. Doug Fridsma, ONC director of standards and interoperability.

ONC plans to release its proposed rule for standards and certification criteria for stage 2 of meaningful use at the end of the year. That means that recommendations must come together by fall, he said.

The ability to share lab results, transitions of care and engaging the patient and public health will be important drivers for providers to move from paper to electronic records. The vocabularies and terminologies that are healthcare-specific are critical to the use of standards and assuring interoperability when systems hand off information, he said.

"We need to begin to reduce alternatives and drive towards those vocabularies and terminologies that are going to be most usable," Fridsma said. "We also need to be pragmatic about what we want people to exchange."

Providing options only makes it more complex for vendors who are developing updates for EHRs. ONC wants to focus on vocabulary centered on lab reporting, care transitions, public heath reporting and quality measures.

"We have to identify vocabulary and code subsets that account for a significant portion of the volume and the value, and covers the range of things that we think are going to be important as we go into stage 2 of meaningful use," Fridsma said.

For example, the standard document formats of HL7's Continuity of Care Document (CCD) and the Continuity of Care Record (CCR) from ASTM International enable providers to share a range of summary patient data. Problem lists, medications and allergies, and lab results will be a pragmatic subset of the patient summary to start with for exchange.

"The kind of thing that will get us to success will [be to] converge to a single vocabulary for a single purpose," Fridsma said, explaining that he doesn't expect a single vocabulary for everything that will be exchanged.

But administrative transactions may be a vocabulary set, lab results another, "and we need to begin converging toward a singular vocabulary for medications," he said.